My friend and colleague Abe Halpern passed away on April 20, 2013. Abe was a remarkable and unforgettable person. He was a loving and dedicated husband, father, grandfather and and great grandfather. He also was a skilled forensic psychiatrist and an activist for many the causes in which he deeply cared about.
Abe and I belonged to the same District Branch (Westchester Psychiatric Society) of the American Psychiatric Association and were both on the faculty of New York Medical College in Valhalla, New York, so I had numerous opportunities to see him in action. I also observed him stand up for his beliefs at the Assembly of the American Psychiatric Association where he introduced various resolutions which were passed due to his persuasive advocacy. He was a reader of this blog and was kind enough to frequently make constructive suggestions to me.
I had the opportunity to sit and down and conduct a one to one recorded interview with Abe where he discussed three topics which were dear to his heart. This interview is presented below in three parts:
Part One – Is there a role for a psychiatrist in the care of a prisoner who is being executed?
Part Two – Is there a role for a psychiatrist in the questioning of a prisoner?
Part Three – Should Marijuana be legalized ?
Born 2/2/1925. Died 4/20/2013 as a result of an earlier fall. His family emigrated to Canada in 1927. As a teenager, he joined the Royal Canadian Navy serving in both the Atlantic and Pacific theaters during WWII. After the Korean War, he was honorably discharged at the rank of Lieutenant Surgeon Commander. A medical school graduate of the University of Toronto, he practiced psychiatry for over 50 years and was a leader in the subspecialty of forensic psychiatry. Awards from the American Medical Association, American Psychiatric Association, and from many other organizations of medicine reflect a life dedicated to human rights. He marched with Martin Luther King, Jr. in Selma, fought against China’s torture of the Falun Gong and illegal organ transplantation, the misuse of the insanity defense, and forced psychiatric hospitalization without judicial review. He was a national and international leader against the involvement of physicians in capital punishment and also physician participation in coerced interrogations of prisoners. All were subject of his prolific publications. He is survived by his beloved wife Marilyn, and his loved children (and spouses) Howard, Lon (Barbara), Marnen (Herdis), Chaia (Adam), Mark (Tomoko), Emily, and John. He was an adoring grandfather of 11 and great-grandfather of 5.
Suicide is the 11th leading cause of all death in the United States. It is one of most important issues which mental health professionals are concerned about in their clinical work. The American Academy of Psychoanalysis and Dynamic Psychiatry of which I have the honor of currently being President, has designated the title of its 57th annual meeting as: Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychodynamic Psychiatry. It is fitting that the meeting is being held in San Francisco which although not on the top 15 cities with the highest suicide rate does have the Golden Gate Bridge as its symbol which is the second most common suicide site in the world.(see previous posts on this subject) Any mental health professional is cordially invited to register and attend this meeting (see AAPDP.org) which will take place May 16-18 2013.
Mental health professional must always consider the suicidal potential of any patient especially when that patient is depressed or experiences significant distress. I recall as a junior psychiatry resident when I first was given the responsibility of making a decision to hospitalize patients (even against their will) because I felt he or she was a danger to themselves (or others). As much as this is a heavy burden, it is likewise a major responsibility not to hospitalize a suicidal patientand face a situation where this person has ended their own life. In the latter case there also is the possibility of legal consequences.
If a person is determined to end his or her own life, they will ultimately succeed. However when the desire to do it is due to a mental condition that we can treat, there is a good chance that we can prevent the suicide if we can intervene and facilitate proper treatment. Unfortunately this is not always the case since patients who are in treatment or who have had treatment do kill themselves.
Depression is the most common condition which has the potential to lead to suicide. This may be part of biological condition with genetic components which brings about severe bouts of depression. Depression may be part of the grieving process or it may be due to complicated psychological reasons which lead some people to be so depressed that they want to end their life
.
Sometimes there is anger at a lost object (person) that gets turned inward leading to self destructive acts. When the ability to test reality is lost, the reasoning for suicidal actions can be quite bizarre and may include internal voices commanding the persons to hurt or kill themselves. There are still other situations where a person does a self destructive act, not with intent to commit suicide but rather with an intent to suffer or manipulate others but inadvertently does die as a result of this gesture. There are certain personality patterns where there may be repeated suicidal gestures which have the potential to be fatal or very harmful. Drugs and alcohol and complicate the problems and may actually be the cause of suicide.
There are some special circumstances where a patient with a serious, very painful or perhaps fatal illness may want to end his or her life or may ask the doctor to facilitate their demise. There are ethical discussions how should this be handled. In some of these situations, if pain and discomfort is better controlled this may not be an issue.
The treatment for a patient with suicidal potential is a delicate situation. First the decision needs to be made if the treatment is to be inpatient or outpatient (sometimes a combination of both). There needs to be a treatment plan that will almost always require psychotherapy frequently with a combination of psychopharmacology. In rare situations ECT (Electric Convulsive Treatment) will be utilized. Family and close friends often play an important role in the support of the person with suicidal thoughts. While psychotherapy needs to be confidential, the patient needs to understand that under certain circumstances where the therapist believes that the patient is an immediate danger to self or others, the therapist may have to break the confidentiality for the benefit of the patient. It goes without saying that there needs to be a trusting relationship with the therapist so the patient understands that there are two people working together in the best interest of the patient.
Many of these topics and others are going to be addressed at the San Francisco meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry May 16-18 at the Westin St Francis Hotel which was mentioned at the beginning of this blog. All mental health professionals are welcome to register either in advance or onsite and attend the meeting . Go to AAPDP.org for more information or you can contact me if there are any questions. There will three plenary sessions by Drs Mardi Horowitz, Jeste Dillip and Herbert Pardes as well as many panels and workshops. There will also be a very interesting documentary about suicide titled, Don’t Change The Subject with a discussion with Mike Stutz, the filmmaker after it is shown. A few of these presentations will be made available to Auto-Digest subscribers but if you are able to attend in person, I suggest that you do so. I look forward to meeting any attendees at the meeting.
The following is an article which I wrote for the current issue of the Forum. This is a publication of the American Academy of Psychoanalysis and Dynamic Psychiatry of which I am the current President.
President’s Message: My Introduction to Telemedicine/Telepsychiatry
By Michael Blumenfield, M.D.
There are many psychiatrists and other therapists who have been involved for at least several years with using computers and video cameras through the Internet to see patients and teach. From time to time over the years I have attended presentations that described the pros and cons of this activity. I recall some of my skeptical colleagues saying until you can smell the patient, they were not getting involved. I always thought that was extreme but recall another statement bandied around that you have to be able to get a very good look into the patient’s eyes in order for this technique to be useful. Still others likened this approach to therapy on the telephone which some favored in rural areas with circumstances where there were no access to in-person therapists.
My interest in this subject was renewed about 3 years ago when I left New York Medical College. I established a practice in Los Angeles and began to explore some new venues. Dr. Elise Snyder asked me if would like to teach and do other activities with the Chinese American Psychoanalytic Alliance program (CAPAChina.org) that used SKYPE and OooVoo to teach classes, supervise therapists, and treat therapists who were in their training program. By this time I had experience using SKYPE communicating with family members and sharing some travel experience live online from far away countries.
CAPA is an extremely well organized program that continues to grow and offers eager Chinese therapists a chance to receive a high-quality two year training program in psychoanalytic therapy. Within a short time after connecting with them, I could not believe that I was sitting in my office talking and interacting with 10-12 Chinese students in three different cities. Needless to say, I do not speak Chinese and to be accepted into the program the Chinese students must be fluent in English.
I was re- reading and discussing some classical psychoanalytic papers which I hadn’t read in many years. I was also learning about some subtle cross cultural concepts. For example, the concept of shame in China is a very important one and is quite different than the concept of guilt which is so important in western culture. I recall one homework exercise I gave the students which was to discuss clinical examples of shame in their therapy work or alternatively from their own life experience. One bright student told how he as a young boy would make up stories of things he said that he did wrong order to show shame which pleased his grandparents and made them very happy.
The opportunity to do one to one supervision and also some individual psychotherapy also revealed new issues reflecting the Chinese experience. For example, a patient after several months in treatment began to mention that when she was five years old, she and her family had to move to the countryside. Her memories about that time seemed to be very benign. Doing some calculations in my mind about the little Chinese history that I did know, I inquired if that wasn’t a difficult time when many people were being punished and treated badly as part of “re-education “ measures. This inquiry led her to begin to rock and back and forth and cry as she recalled that that was a terrible time in the history of her family.
|
In other ways the issues of trust, speaking freely and the resistances to doing so are important in therapy but are colored by the Chinese culture and the prevailing changing atmosphere in China. All this was very enlightening to me and emerged from my limited work with CAPA and telepsychiatry. My work with CAPA led to me to going on a CAPA study tour where I was able to lecture in China, meet some the students in person and attend the student graduation program in Beijing.
Our experience with CAPA led my colleague Dr. Jim Strain and I to set up a non-profit teaching program in Psychosomatic Medicine for third world countries (PSMWW.com). We had decided to do this rather than write a second edition for a large textbook we edited in the above field. We thus far have taught two 8-session courses in South America and in Rwanda via teleconferencing. One of the systems we use allows us to share our computer screen and that makes the projection of PowerPoint sides particularly useful. However the most meaningful part of the teaching is the direct interaction with the students. This exposure, and the nature of the teaching material we have chosen that is greatly influenced by psychodynamic experience, is also proving to be interesting from a cross cultural point of view.
I had a completely different experience when I signed up to work one half-day a week with the California Telepsychiatry Group (caltelepsych.com/) that is part of American Telepsychiatrists led by Dr. John Schaffer. This group has a contract to provide psychiatric care via video conferencing for several mental health clinics in central California.
They use a system called Web-Ex which seems to be even better than SKYPE and OOVOO. They also have a sophisticated online electronic medical record that I can easily access as well as an online prescribing system called Infoscriber where I can directly prescribe to any pharmacy in California.
American Telepsychiatrists has many other sophisticated features. The sessions take place in a private room in a clinic while I am comfortably in my office in Los Angeles. I have a psychiatric nurse present with the patient and/or a translator when needed. While I am doing mainly psychopharmacology, I can refer the patient to individual and group therapy, to primary care physicians, and to substance abuse programs, and I can order lab work, communicate with other health care workers, and send patients directly to the hospital or do anything that I might do from my private office. The psychiatric nurse with whom I work, and the staff, are helpful and supportive. Patients adjust easily to this form of communication and most of them are extremely appreciative of the care that th
ey are receiving.
Only recently have I considered using telepsychiatry in my private office practice. There were two instances where college students with whom I was working were going back to college and they wanted to continue their sessions while they were away at school. They were very comfortable with SKYPE and one of them used it on his i-phone. The therapy didn’t miss a beat. One session took me zooming from room to room as the student’s roommate had unexpectedly appeared and the patient was trying to keep his therapy confidential.
I started using SKYPE to treat a new patient who was from another city and expected to be traveling to Los Angeles from time to time for occasional face-to-face sessions. Of course resistance and transference issues have to be considered when there is the lack of an in-person presence. Recently a patient being seen through SKYPE asked if I would mind if he lit up a cigarette. That issue hasn’t come up in over 20 years since I removed the ash trays from my office. So while the smoke wouldn’t bother me, of course I had to explore the patient’s state of mind for wanting to light up at that time.
We are becoming more of a global society. AAPDP is having an increasing number of international members. We comfortably travel in airplanes and through the Internet. It seems only logical that we should take our professional lives with us on these journeys.
IMPORTANT ADDENDUM: Please see link to an important statement about this topic at the end of the blog
I personally favor strict gun control laws. I also believe that that there should not be stigma against people with mental illness. People should be able to see a mental health professional with the confidence that their treatment will be confidential. The exception to this latter point is when the mental health professional believes that the person is a danger to themselves or someone else, the mental health professional is obligated to act and notify police if indicated and/or hospitalize the patient. This obligation should not be a secret to the patient and anyone seeing a therapist should understand that would be the appropriate and ethical behavior to be followed in those circumstances.
There may very well be a conflict in the first sentence in the above paragraph and the statements which follow. My thinking about this subject was stimulated by a recent op-ed piece in the NY Times by Ms. Wendy Burton a former political speech writer titled “Please Take Away My Right to a Gun” . Ms Burton argues although she might be tempted to get a gun for self protection she also realizes that her depression condition would make her more likely to use it against herself.
She quotes statistics from the Center for Disease Control and Prevention that 38,364 Americans committed suicide in 2010 and 19,392 used a gun.
Federal Law Concerning Mental Illness and Right to Own a Gun
Possession of a firearm by the mentally ill is regulated by both state and federal laws. The federal law states “ It is unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person “has been adjudicated as a mental defective or has been committed to any mental institution.” Mentally defective is obviously an outdated term and I am guessing that would probably be interpreted to mean mentally disabled. (meaning low IQ or significant brain damages etc ). I assume that the term “committed“ to a mental institution means some type of legal involuntary hospitalization. However, I believe that in some states a person can sign themselves in to a hospital and be considered to be “committed” and can be held against their will for a certain period of time even if they change their mind and wish to leave. If a person is held in a mental hospital against their will but then is released by a judge or by another or more senior doctor after the circumstances are clarified, is that person considered to be committed?
What about a person who voluntarily enters a mental hospital to be treated for a mental condition completly unrelated to any potential violence. For example hospitalization for anorexia, incapacitating obsessive compulsive disorder, addiction to pain medication prescribed by doctors etc. In fact if the condition was such that the person couldn’t care for themselves, they might have even been admitted on an involuntary basis (“ committed “).
State Laws Concerning Mental Illness and Right to Own a Gun
Now I wondered about the wording of the various state laws. I went to the NCSL-National Conference of State Legislatures website . All I can say is that it is quite a mixed bag on this subject. My state of California says the following :
A person is barred from possessing, purchasing, receiving, attempting to purchase or receive, or having control or custody of any firearms if the person:
Oklahoma law briefly states : Oklahoma prohibits knowingly transferring a firearm to:
Texas goes into a great deal of detail :
A person is ineligible for a license to carry a concealed weapon if the person:
(1) has been diagnosed by a licensed physician as suffering from a psychiatric disorder or condition that causes or is likely to cause substantial impairment in judgment, mood, perception, impulse control, or intellectual ability;
(2) suffers from a psychiatric disorder or condition described by Subdivision (1) that: (A) is in remission but is reasonably likely to redevelop at a future time; or (B) requires continuous medical treatment to avoid redevelopment;
(3) has been diagnosed by a licensed physician, determined by a review board or similar authority, or declared by a court to be incompetent to manage the person’s own affairs; or
(4) has entered in a criminal proceeding a plea of not guilty by reason of insanity.
The following constitutes evidence that a person has a psychiatric disorder or condition described by section (1), above:
(1) involuntary psychiatric hospitalization;
(2) psychiatric hospitalization;
(3) inpatient or residential substance abuse treatment in the preceding five-year period;
(4) diagnosis in the preceding five-year period by a licensed physician that the person is dependent on alcohol, a controlled substance, or a similar substance; or
(5) diagnosis at any time by a licensed physician that the person suffers or has suffered from a psychiatric disorder or condition consisting of or relating to:
(A) schizophrenia or delusional disorder;
(B) bipolar disorder;
(C) chronic dementia, whether caused by illness, brain defect, or brain injury;
(D) dissociative identity disorder;
(E) intermittent explosive disorder; or
(F) antisocial personality disorder.
The other states vary greatly. Take a look at that link .
Of course the big question might be how is this information determined.
Hospital Records, Gigantic Database or Honor System?
Will the information used to prevent someone from getting a gun permit come off of insurance records, Medicaid, Medicare forms etc? Will there be a gigantic database of all mental health treatment? Or will this just be the honor system of the person applying for a gun permit? What will happen if someone reports to the government that they know so and so was treated for a mental condition by such and such doctor or hospital and shouldn’t have a gun permit? Will mental health professionals have to release their records or have to testify about their non- hospital treatment? Will there be any obligation if a therapist learns in the course of therapy that a patient is applying for a gun permit but actually doesn’t meet the criteria of the state or perhaps of some new all encompassing federal law??
Let’s Have a Dialog About This Subject
Now is the time for mental health professionals to join in the dialog that this country is going through. Let’ start it here. There are about 15,000 viewers /week on this blog according to the statistics which I get from word press but you are usually exceedingly reticent to send in comments. Perhaps this subject can be the exception. It may be very helpful to mental health professionals and patients if we participate in this national discussion. Please click on the comments button and let’s hear your thoughts on this subject. What should the law be concerning mental illness and the right to own a gun and how should such a law be worded? I also encourage readers outside the United States give us your viewpoint.
ADDENDUM: I was very pleased to see a recent letter by Dilip Jeste, M.D.President of the American Psychiatric Association which makes some very important points on this subject. Click here for the link 
I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.
I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.
Psychological Trauma
Common wisdom and research in this area tell us that the closer a person is to the traumatic event, the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected. This would include anyone in the school who heard sounds and participated in the terror of hiding and escaping from danger.
The two conditions that will emerge from such an incident are Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :
The person has been exposed to a traumatic event in which both of the following were present.
1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.
2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)
In addition for us to make a diagnosis of ASD there needs to be three or more symptoms such as numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased anxiety and arousal with sleep and concentration problems and a duration of these symptoms 2 to 4 weeks.
In order for us to make diagnosis of PTSD there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response impairment in social functions, with a t least one of these symptoms lasting more than one month.
For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )
Trauma Not Limited to Immediate Geographic Area
The development of these symptoms is not limited to people in the immediate vicinity.
Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event
I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.
Long Term Effects
It should be recognized that the acute and long term psychological effects of this trauma goes beyond the two disorders described above The experience also becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.
The Need for Immediate Psychological Intervention;
There has immediately been an outpouring of offers of psychological help.
I am sure the school system ,local and state agencies will bring in counselors and therapists. Local mental health professionals will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful or a combination can be used. For some of the children, the comfort of discussions and interactions with their parents will be most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions and directly dealing with ideas and behavior and psychodynamic therapy where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers can be used and when conditions such as major depression is identified, antidepressants may be prescribed. Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.
Grieving the Loss of Life.
As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful
Concern About Other Disturbed Individuals Including Copycat Incidents
It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.
The Overwhelming Majority of People with Mental Illness are Not Dangerous
Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.
The Gun Control Issue and The Psychological Implications.
We don’t yet know the history and the story why the Connecticut shooter’s mother had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the chances are, not as many people would have been killed.
I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.
